Is your physician practicing medicine or policy?

Most patients assume the treatment options presented in the exam room are the full menu. But behind the scenes, many physicians are quietly editing out possibilities—because insurance won’t cover them.

In this episode of The Talking Rehab Podcast, Dr. Fred Bagares shares what it feels like to practice medicine through the lens of a policy manual, why “covered” doesn’t always mean “available,” and how direct care restores the conversation between physician and patient.

You’ll discover:

• Why coding shortcuts shape more than just paperwork—they shape outcomes
• How treatments with decades of evidence still get labeled “experimental”
• Why direct care isn’t about rejecting insurance, but reclaiming clinical freedom

🕰 Timestamps + Key Themes

[00:00] The Hidden Filter
How insurance quietly edits what gets discussed in the exam room.

[02:00] Coverage ≠ Credibility
Why patients and physicians alike equate coverage with value—and why that’s misleading.

[04:00] The Denial Letter
Shockwave therapy as a case study in how policy trumps science.

[06:00] The Coding Trap
When diagnoses are shaped by billing efficiency, not clinical accuracy.

[08:00] The Ceiling of the Insurance Model
Why high-volume care trains young doctors but stifles long-term growth.

[10:00] The Reframe
Insurance as a voucher—it covers part of the menu, but not the whole kitchen.

[12:00] What Direct Care Restores
Precision, time, and the ability to think beyond policy boxes.

[13:00] Patient & Clinician Challenges
The questions that shift conversations and the mindset shifts that matter most.

👉 If this episode reframed how you think about insurance and medical care, hit subscribe and share it with someone who needs to hear it. For clarity on your own recovery options, visit FredBagares.com.

Transcript

0:00

What if the Vari system designed to give you access to care is the same one quietly taking your best options away? I know that sounds dramatic, but here's the thing. I've been on both sides of this conversation. I've sat across from patients explaining treatment plans while mentally editing out the options. I knew their insurance would never approve. I've watched people nod along trusting that what I was offering them was the full menu when really it was just what fit inside a very specific box. And I remember the exact moment. I realized I wasn't practicing medicine the way I was trained to. I was practicing medicine the way a policy manual allowed me to today, we're going to talk about something. Most patients never see how insurance coverage pays for a certain type of care, which can shape what gets discussed in the room. We'll explore why covered doesn't mean available, how diagnostic codes quietly dictate clinical thinking and why direct care isn't about abandoning insurance, but about reclaiming the conversation between the physician and the patient. This isn't an anti insurance rant. Insurance has its place, but if you've ever felt like your options were limited or wondered why certain treatments never even came up, this episode might explain why. This is what we're gonna explore today. I'm Dr. Fred Biris, and this is The Talking Rehab Podcast. Quick favor, before we dive in. If this podcast has changed how you think about your body or your recovery, hit that subscribe button. It's free. It takes two seconds, and it's how we keep bringing you these conversations every week. No fluff. Just real talk about what actually works. Thanks for being here. Now let's get into it. Let's start with the belief. Most of us hold without question. If my insurance covers something, it must be the best available option. It makes sense, right? We assume that insurance companies with all their resources and research teams have vetted the treatments they approve. We think coverage equals credibility. And on the flip side, if something isn't covered, it must be experimental, unproven, or unnecessary. Clinicians fall into a similar trap. We start to equate coverage with feasibility. If it's not reimbursable, it's not practical. If there's no code for it, it's not real. Here's a small example that illustrates how this plays out. Lumbar stenosis versus lumbar radiculopathy. Both are spinal conditions and can exist together or independently. Both cause pain, numbness, and functional limitations. But in the world of insurance coding, they live in very different neighborhoods. Lumbar stenosis. The narrowing of the spinal canal has a very clear, well-established diagnostic code. It triggers certain reimbursement pathways, justify specific imaging, and opens doors to surgical consultations. Lumbar radiculopathy, nerve root irritation gets too, but often lumped together with a dozen other things under a broader category. The clinical nuance gets lost and when the nuance disappears, so do the treatment options. Now, here's where things get tricky. A patient might have both, or they might have something that doesn't fit neatly into either bucket. But because we're coding for reimbursement, not precision, the diagnosis on paper might not reflect the full picture. And if this diagnosis isn't accurate, the treatment plan that follows won't be either. This isn't a mistake. It's a system working exactly as it's designed, but it's not designed for clinical accuracy. It's designed for billing efficiency. I'll never forget the day I saw well researched. Treatment plan denied as experimental. The patient had chronic Achilles tendinopathy, years of failed physical therapy, multiple rounds of injections, and a surgeon telling them they weren't a good surgical candidate. Shockwave therapy has decades of evidence behind it. Peer reviewed studies, international guidelines, recommending it as a frontline intervention, but the insurance company flagged it as investigational. I remember sitting in my office staring at the denial letter thinking, this isn't about the science. This is about someone's spreadsheet, and that's when the weight of it hit me. Every time I had a conversation with a patient, I was running two parallel scripts in my head. One was clinical, what does this person need? The other one was administrative. What will they cover? Over time, the second script started to dominate, not because I stopped caring, but because I got tired of the emotional toll. It's exhausting to discuss options. You know, patients can't access. It's demoralizing to watch someone's face fall when you explain that the treatment you think would help them the most isn't on the approved list. So you start to adapt. You stop mentioning certain options. You default to what's covered. You tell yourself it's practical, not compromise, but here's the truth. I wasn't practicing medicine filtered through policy. I was starting to think through the policy, and that's when I knew something had to change. Let's talk about what happens when treatments with decades of evidence still gets labeled as experimental. As I said, shockwave therapy isn't new. Platelet rich plasma has been studied extensively. But both of these, despite the research, despite the clinical outcomes, regularly gets denied by insurance. Why? Because experimental doesn't mean scientifically unproven. It means not yet absorbed into the reimbursement model. There's a lag between what research shows and what policy covers. However, I suspect that this is somewhat intentional and patients get caught in that gap. Now let's dig into something. Most people never think about the actual codes themselves. Hip and spine syndrome is a perfect example. It's a recognized clinical pattern. Hip pathology that mimics lumbar spine issues and vice versa. Patients with this condition often get misdiagnosed, sent down the wrong treatment pathway and end up frustrated because nothing works. But there's no ICD 10 code for hip and spine syndrome. So even though we see it, even though it's clinically significant, it doesn't exist in the language of billing. And if it doesn't exist in billing, it doesn't get studied properly. It doesn't get discussed in treatment guidelines. It gets lost, or let's take radiculopathy versus radiculitis. Clinically, these are very different. Radiculopathy is nerve root dysfunction with objective findings, weakness, reflex changes, measurable deficits. Radiculitis is attributed to inflammation around the nerve root, often painful, but without the same level of structural compromise. This, the distinction matters for treatment, but in coding, they're often lumped together. And when that happens, research studies that rely on diagnostic codes miss this nuance. We end up with bias data because the categories we're studying don't reflect the actual clinical picture. Now, here's something I don't think gets acknowledged enough. The insurance based model is actually valuable early in a physician's career. The volume does matter when you're actually learning. Seeing dozens of patients a week builds pattern recognition. You get good at triaging, you learn to move efficiently to spot red flags, to trust your clinical instincts. So there are benefits to having a high volume clinic. It's a bootcamp and it can be very effective. However, there is a ceiling. As you mature as a clinician, the cases that interest you, the ones that challenge you, the ones that require deeper thinking, they don't often fit into a 15 minute slot. You need time bandwidth, and the freedom to say, I don't know yet, but let me think about this. The insurance model stifles that growth, not because physicians aren't capable, but because the system doesn't reward curiosity. It rewards coding and billing. As a young resident, I was very focused on learning the billing codes because I didn't want to mess up anything for my attendings. However, when you have to start searching for new codes or realize that certain codes aren't getting paid for, it does change your behavior. Here's where I want to be really honest. Physicians start coding for ease, not accuracy, and it's not because they're lazy or indifferent, it's because they're just simply trying to survive. When you're seeing 30, 40, 50 patients a day, you don't have time to deliberate over whether something is best coded as M five, 4.5, or M five 4.16. You pick what's fastest, what's safest, and what won't get rejected. Over time, those shortcuts become habits, and habits become the way you think the system isn't designed to. The system isn't designed to erode diagnostic accuracy, but that's the unintended consequence, and the patients are the ones who have to pay the price. Now, here's where I need to be transparent. Leaving the insurance system didn't mean I stopped playing the insurance game completely. I still code when I have to refer patients out for imaging. I still navigate insurance requirements when I'm coordinating with other specialists or prescribing certain medications. The difference is this, i'm no longer letting those codes dictate how I think. When I sit down with a patient now, I'm not running that second script in my head. I'm not preemptively editing my clinical reasoning to fit a reimbursement model. I can be precise. I can take time. I can say. Here's what I think is happening, and here's why it doesn't fit the usual categories. That freedom to diagnose without policy boxes is what direct care gave me back. Not the absence of codes, but the ability to think beyond them. So here's the reframe. Patient options are not the same as insurance options. Think of it like this. You walk into a restaurant with a voucher that covers five items on the menu. Those five items are good. They're nutritious, they fill you up, but the restaurant has 30 different items. And some of those other 25 items might be actually what you need better for your dietary restrictions, more aligned with your preferences. Higher quality ingredients. The voucher isn't worthless. It does give you access, but it's not the full menu. Insurance works the same way. It's a financial tool. It provides access to a subset of care. But when we mistake that subset for the entirety of available options, we limit ourselves. For clinicians, this reframe is just as important. The insurance model is a great training ground. It builds competency, but it's a terrible ceiling if you want to mature as a physician. If you want to sharpen your diagnostic accuracy, recognize rare conditions, and have the bandwidth to think deeply, you need a different structure. Direct care isn't about rejecting insurance. It's about reclaiming clinical freedom. It's about saying, I want to be reimbursed fairly, but I don't want it to dictate the way I practice medicine. And for the patients, it's about reclaiming your agency. It's about returning the decision making process to where it belongs. The conversation between you and your physician, not you, your physician in some policy manual. Let me bring this back to something concrete. If you're a patient, here's what I want you to know. Insurance is a safety net. It's essential for catastrophic care, hospitalizations, surgeries, but it's not the ceiling of what's available to you. If you've been stuck, if treatments aren't working, if you feel like your options are limited, ask your doctor. What would you recommend if insurance wasn't a factor? That question changes the conversation. For clinicians. Here's my challenge. Ask yourself, am I just coding or am I truly diagnosing? Are my treatment plans shaped by clinical thinking or by my reimbursement pathways? If the answering makes you uncomfortable, that discomfort is information that you should pay attention to. And if you're curious about how direct care creates space for same day clarity, personalized protocols, and long-term partnerships without gatekeepers. That's exactly what I've built my practice around. No insurance lag, no pre-authorization, Just the bandwidth to work harder for my patients and not spend too much time on some arbitrary policy manual that doesn't even really provide excellent care. Insurance offers financial coverage. It is valuable, especially early in a career when volume builds competency, but over time, it narrows long-term diagnostic freedom. It compresses thinking and it limits growth. When I left the insurance system, I stopped asking what will they cover, and started asking, what does this person truly need? That's when my practice and my patients began to grow. So here's my challenge to you. Patients. Don't confuse coverage with choice. Clinicians don't confuse policy with progress. And if you want clarity on what your real options are without a system dictating the menu, please visit fred baggers.com. Thanks again for your time. Thank you for listening to The Talking Rehab podcast. I hope that this podcast stimulates you to question your own practice and how you approach rehabilitation. I truly appreciate your time and attention. If you enjoyed listening, make sure to like and subscribe to the podcast. I wish you a movement filled day. Take care.